On March 25, Joseph Johnston, Juvenile Court Justice in Boston, Massachusetts, issued a disposition order in the case: Care and protection of Justina Pelletier. The background to the case is well-known. Justina is 15 years old.
Judge Johnston did not return Justina to the care of her parents, but instead granted permanent custody to the Massachusetts Department of Children and Families (DCF), with a right to review in June.
In paragraph 4, the disposition order states:
“At trial there was extensive psychiatric and medical testimony. Voluminous psychiatric and medical records were entered in evidence. Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder. On December 20, 2013, this court found the MA DCF sustained its burden by clear and convincing evidence that Justina Pelletier is a child in need of care and protection pursuant to G.L c. 119, §§ 24-26 due to the conduct and inability of her parents, Linda Pelletier and Lou Pelletier, to provide for Justina’s necessary and proper physical, mental, and emotional development.”
This is the substantial finding of the court, and it is noteworthy that there is no mention of the mitochondrial disease which had been Justina’s earlier diagnosis and for which she had been receiving treatment at Tufts Medical Center, Boston.
The disposition order is somewhat terse and sparing in its tone, but reading between the lines, it seems clear that the court has determined that Justina either does not have mitochondrial disease or that, even if she does have mitochondrial disease, her concern about this matter is inappropriate and excessive. There is also the suggestion that her parents, Linda and Lou Pelletier, have contributed to Justina’s preoccupations in this regard, and that for this reason, Justina needs to be protected from them. As in all cases of this kind, a great deal of the information is kept confidential. So we are inevitably working with incomplete information.
Obviously there are many issues that might be raised, and these are being addressed by others, but I would like to focus here on the “diagnosis” of somatic symptom disorder.
DSM-5 describes somatic symptom disorder as: “…distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms.” A “diagnosis” of somatic symptom disorder can be assigned even if the person really does have an actual illness, provided that the person’s response to the symptoms of the illness is excessively distressing and disruptive.
Here are the actual diagnostic criteria as set out on page 311 of DSM-5:
Somatic Symptom Disorder 300.82 Diagnostic Criteria
A. One or more somatic symptoms that are distressing or result in significant disruption of daily life.
B. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:
1. Disproportionate and persistent thoughts about the seriousness of one’s symptoms.
2. Persistently high level of anxiety about health or symptoms.
3. Excessive time and energy devoted to these symptoms or health concerns.
C. Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).
With predominant pain (previously pain disorder): This specifier is for individuals whose somatic symptoms predominantly involve pain.
Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months).
Specify current severity:
Mild: Only one of the symptoms specified in Criterion B is fulfilled.
Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.
Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).
DSM-5 (p 830) defines a symptom as: “A subjective manifestation of a pathological condition. Symptoms are reported by the affected individual rather than observed by the examiner. Compare with SIGN.” On page 829 they define a sign as: “An objective manifestation of a pathological condition. Signs are observed by the examiner rather than reported by the affected individual. Compare with SYMPTOM.” This kind of terminology has become standard in general medicine. A symptom is something reported by the patient (e.g. abdominal pain); a sign is something observed by the examiner (e.g. distended abdomen). Symptoms and signs are the twin pillars of medical diagnosis.
“Somatic” means bodily or physical, as opposed to mental.
So criterion A requires that the individual reports at least one physical symptom, and that this symptom is distressing and results in significant disruption of daily life. Distress and significant disruption are vague concepts, the assessment of which is clearly dependent on the psychiatrist’s subjective judgment.
Here again, we have a great deal of subjectivity. Words like “excessive” and “disproportionate” are open to individual interpretation, and there are no objective standards by which the accuracy of the diagnostic decision can be assessed.
Ultimately, a person will meet the requirements of criteria A and B if, and because, a psychiatrist says so. There is no objective reality against which the psychiatrist’s assessment can be checked. The psychiatrist’s subjective assessment is the only test for a “diagnosis” of somatic symptom disorder.
So when a psychiatrist says that a person “suffers from somatic symptom disorder,” all that this means is: “In my opinion this individual is excessively preoccupied with physical symptoms and that, also in my opinion, this preoccupation is causing significant disruption in his/her life.”
The APA, by including this “diagnosis” in their diagnostic manual, assigning it a name and number, and listing the diagnostic criteria, create the impression that this is a real illness, and distract attention from the central fact: that the only reality here is a psychiatrist’s opinion.
The only justification for the assertion that Justina Pelletier “suffers from a persistent and severe Somatic Symptom Disorder” is a psychiatrist’s subjective opinion. In fact, the statement “Justina suffers from somatic symptom disorder” means: “A psychiatrist believes that Justina’s concern about her symptoms is excessive.” These two statements are absolutely equivalent. The first statement, despite its appearance of objectivity, contains no additional substance over the second.
Conflicts of Interest
This deception is the foundation of modern psychiatry. But it doesn’t just occur at the point of individual assessment. It also applies to the invention of these illnesses in the first place. Somatic symptom disorder, like all psychiatric diagnoses, is considered to be an illness because the APA say so. And individuals are considered to have a particular psychiatric “illness” because an individual psychiatrist says so. It’s all based on subjective opinion. And subjective opinion is notoriously unreliable.
But it is particularly unreliable when there are conflicts of interest. The notion that all significant problems of thinking, feeling, and/or behaving are illnesses is central to the APA’s survival. When the day comes – as it surely will – that it is recognized that these problems are not illnesses, then psychiatry will go the way of astrology and phrenology. It will cease to exist. Psychiatry’s foundation is an enormous deception, and in my view psychiatrists know this. But they are fighting for their very existence. The conflict of interest isn’t just about money; it’s also a matter of their professional identity. As a group, they are so invested in the notion of psychiatric illness that they have rendered themselves incapable of honestly and objectively addressing the question: are these problems really illnesses?
In this context, psychiatrists frequently point out that diagnoses in general medicine sometimes involve a physician’s opinion. This is true, but misses the point. When a real doctor says: In my opinion, this person’s diagnosis is X, what he’s saying is that he’s not 100% sure what the actual physical etiology is, but his best assessment at that point in time is X. In psychiatric “diagnosis” there is no reality against which the “diagnosis” can be checked. There is nothing but the psychiatrist’s opinion.
At the present time, small numbers of individual psychiatrists are seeing the light, and are courageously struggling with these conceptual issues. But organized psychiatry in the form of the APA is actually doubling down and fighting harder than ever to prop up the deception that is crumbling like a sandcastle in a flowing tide.
And, of course, there is a huge conflict of interest for individual psychiatrists during their initial evaluations. The psychiatrist’s bill, whether it’s sent to a private insurance carrier, or Medicare, or other reimbursing entity, depends for its legitimacy on the diagnosis. Without a diagnosis, the psychiatrist doesn’t get paid!
So the situation is this: the “diagnosis” is based entirely on the psychiatrist’s subjective opinion; and the psychiatrist’s paycheck depends entirely on the diagnosis. Not surprisingly, psychiatrists manage to “uncover” a great many diagnoses. In fact, the psychiatric leadership routinely and confidently claim that at any given time about ¼ of the US population has a mental disorder/illness, and that the lifetime prevalence is a staggering 50%. They remain blind to the fact that these figures are driven by their own interest-invested need to create more “diagnoses” with progressively lower thresholds, and by their members’ equally self-serving need to assign more “diagnoses” in individual cases.
And this is the background against which Judge Johnston felt confident enough to write:
“Based on credible psychiatric and medical evidence this court has found that Justina suffers from a persistent and severe Somatic Symptom Disorder.”
I truly cannot think of any significant field of human endeavor in which such far-reaching decisions would be made on the basis of such poor evidence. And bear in mind, Justina’s is by no means an isolated case.
If parents are abusing or neglecting their children – and obviously these things do happen – then some kind of intervention is appropriate. But interventions of this sort should always be based on clear evidence and with due regard to the rights of the parents and the rights of the child. But a “diagnosis” of somatic symptom disorder, by its very definition can never reach the standard of clear evidence.
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This article first appeared on Philip Hickey’s
Behaviorism and Mental Health blog.
Philip Hickey is a retired psychologist. He has worked in prisons (UK and US), addiction units, community mental health centers, nursing homes, and in private practice. He and his wife, Nancy, live in Colorado, and have four grown children.